Prostate Abnormalities and Screening

Prostate Abnormalities

• Prostate abnormalities are a significant health concern in men.
• Screening, diagnosis and management strategies are crucial.

Topic Outline

• Prostate cancer screening
  • Digital rectal exam (DRE)
  • Prostate-Specific Antigen (PSA)
  • Serum Acid Phosphatase
• Prostate biopsy
• Normal variants of the prostate
• Inflammatory processes of the prostate
• Cysts of the male pelvis
• Benign Prostatic Hyperplasia (BPH)
• Prostate Cancer

Digital Rectal Exam (DRE)

• A physical exam to check for prostate abnormalities.
• Typically begins between ages 40-50, depending on risk factors.
• Assess for any palpable lesions or general prostate enlargement.
• Used with PSA to determine further evaluation needs.
• TRUS (transrectal ultrasound) may be used to follow-up.

Prostate Cancer Screening Tests

• Used to detect prostate cancer in asymptomatic men at an early stage, for early intervention to improve treatment outcomes.
• Allows for curative treatment in most men.
• Screening should start at age 50 (40 if family history).
• Includes annual DRE and PSA tests.
• Serum acid phosphatase test is also used, but screening ends at age 75.

Serum Acid Phosphatase

• An enzyme secreted by the prostate, normally found in semen.
• Prostate dysfunction can result in detectable levels in the bloodstream.
• Also produced by liver, spleen, blood cells, and bone marrow.
• Not specific, meaning it can indicate other conditions besides prostate issues.

Prostate Specific Antigen (PSA)

• A tremendous advance in prostate cancer management and diagnostics.
• An enzyme secreted by prostate ducts.
• Helps in liquefying semen.
• Normal levels are below 4ng/mL.
• Elevated levels can indicate cancer, though some men with BPH or inflammation may also have normal levels.
• Testing should be ordered before DRE in some cases.

Prostate Biopsy

• Typically done at the time of TRUS (transrectal ultrasound)
• Can be cancelled if the results of the biopsy are negative.
• Pre-biopsy considerations include antibiotics and anticoagulant discontinuation.
• Similar to other core biopsy procedures.
• Requires informed consent.
• Local anesthetic is used.
• Multiple samples of prostate tissue are often collected.
• Patients typically stay in the department for about one hour after the procedure.
• 18 or 14 gauge needle typically used.

Normal Variants of Prostate Gland

• Benign Ductal Ectasia:
  • More common with advancing age.
  • Prostate tissue atrophies and ducts dilate.
  • Seen as 1-2mm tubular structures on ultrasound.
  • May present as a hypoechoic mass.
• Prostate Calcifications:
  • More common with age.
  • Appear as bright, echogenic foci on ultrasound.
  • Sometimes present with shadowing or twinkle artifact.

Inflammatory Processes of Prostate Gland

• Prostatitis is inflammation of the prostate and seminal vesicles, either acute or chronic.
• Acute Prostatitis:
  • Presents with typical inflammatory symptoms (fever, chills, pain, dysuria).
  • Ultrasound role is limited by severe pain and difficulty with TRUS/DRE.
  • Ultrasound appearance can mimic carcinoma.
  • Can present as a hypoechoic gland with abnormal vascularity.
  • Possible abscess formation may be present as an anechoic mass.
• Chronic Prostatitis:
  • Associated with conditions like chlamydia or mycoplasma as well as no apparent cause.
  • Presents with non-specific symptoms such as dysuria, frequency, urgency, hematospermia, pain.
  • Appearance may include focal masses of variable echogenicity, ejaculatory duct calcifications, capsular thickening, dilated periprostatic veins, and distended seminal vesicles.

Cysts of the Male Pelvis

• Prostatic utricle cysts:
  • Small pouch on posterior side of prostatic urethra.
  • Often appear midline, tear-drop shaped.
• Mullerian duct cysts:
  • Remnants of Mullerian duct, never contain sperm.
  • Often appear tear-drop shaped, pointed towards verumontanum.
• Ejaculatory duct cysts:
• Cystic dilation of ejaculatory duct.
  • Contain sperm.
  • Typically associated with infertility.
• Seminal vesicle cysts:
  • Remnants of Wolffian duct.
  • Can be large.
  • Often requires aspiration.

Benign Prostatic Hyperplasia (BPH)

• Benign enlargement of prostate gland, common finding in older men.
• Symptoms may include hesitancy, starting and stopping of urination, frequent urination, oliguria, and/or hematuria.
• Sonographic appearance includes a larger gland, specifically an inner (transition zone) gland enlargement.
• Potential for calcifications of the gland, as well as for cysts to be present.
• TURP could cause a large defect in the gland to be seen on imaging.

Prostate Cancer

• Most common cancer in men; second leading cause of cancer deaths in men (after lung cancer)
• Typically affects males over 50 years of age.
• Locations:
  • 70% in peripheral zone, 20% in transition zone, 10% in central zone.
• Clinical Symptoms:
  • Symptoms can include frequency, hesitancy, starting/stopping of urination, urgency, and weak stream.
• Sonographic Appearance:
  • 30-40% of prostate cancers undetectable by ultrasound imaging.
  • Biopsy required if DRE or PSA suspicious.
  • Most hypoechoic, but some can be isoechoic or hyperechoic.
  • Increased vascularity visible via Doppler interrogation.
• Treatment:
  • Watchful waiting for low-grade tumors, often based on 10-year life expectancy.
  • Radical prostatectomy (surgical removal), potentially leading to infertility and incontinence.
  • Radiation therapy, external beam, or brachytherapy (implanted radiation seeds).
  • Palliative therapy to manage pain and other symptoms.